- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $2,454.71
| Facility | | $794.33 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $1,174.90 / $2,754.23
| Professional | | $269.15 | $1,174.90 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $288.40
| Facility | | $208.93 | $208.93 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $346.74 / $776.25
| Facility | | $128.82 | $346.74 | $776.25 |